Simultaneous pancreas-kidney transplantation (SPKT) is the procedure of choice in our program to treat type I diabetic patients with end-stage renal disease. Its value in type II diabetic patients remains to be carefully evaluated. With the improvements in the technical results and immunosuppression medications, the procedures have become safer than those performed in the previous decade. However, the diabetic host is a high-risk individual. Careful evaluation and selection is prudent to maintain excellent results with this scarce organ. As we have seen in this series, death is the number one cause of graft loss and improved pre-operative evaluation will continue to be of significant value to lower the mortality rate of SPKT. The success of SPKT has led to wider application of this procedure to less than ideal recipients. Due to the shortage of organs, there is a trend to use more marginal donors. The use of marginal donors and marginal recipients requires careful evaluation to maintain safety and cost effectiveness. At our center, long-term patient and graft survival rates have been acceptable. We will continue to use SPKT as the procedure of choice for acceptable candidates. There has been a trend to change our philosophy to use living donors for the kidney transplant followed by a sequential pancreas transplant in order to overcome the shortage of organs. The issue of primary enteric drainage has not been addressed in this report due to our success with bladder drainage, as we feel that it is a safer procedure and are comfortable that patient education and outpatient therapy has minimized the problems with its use. Despite the lower threshold for enteric conversion, fewer than 10% of our patients undergo conversion when they are at low risk for complications.